Provider Demographics
NPI:1770583163
Name:IVANOV, ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:IVANOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-3196
Mailing Address - Country:US
Mailing Address - Phone:908-722-6410
Mailing Address - Fax:908-722-4638
Practice Address - Street 1:465 UNION AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3196
Practice Address - Country:US
Practice Address - Phone:908-722-6410
Practice Address - Fax:908-722-4638
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073897207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8916403Medicaid
NJH58148Medicare UPIN
NJ8916403Medicaid